Healthcare Provider Details

I. General information

NPI: 1235620600
Provider Name (Legal Business Name): AARON NEIL LARSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S MAIN ST STE 100
SALT LAKE CITY UT
84101-3194
US

IV. Provider business mailing address

4460 S HIGHLAND DR
SALT LAKE CITY UT
84124-3543
US

V. Phone/Fax

Practice location:
  • Phone: 801-567-3618
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: